Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

Background

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

Methods

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

Results

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

Conclusions

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.     

Covered stents in cervical anastomoses following esophagectomy

Introduction

Anastomotic complications after esophagectomy are relatively frequent. The off-label use of self-expanding covered metal stents has been shown to be an effective initial treatment for leaks, but there is a paucity of literature regarding their use in cervical esophagogastric anastomoses. We reviewed our outcomes with anastomotic stenting after esophagectomy with cervical esophagogastric reconstruction.

Methods

All stents placed across cervical anastomoses following esophagectomy from 2004 to 2014 were retrospectively reviewed. Indications for surgery and stent placement were collected. For patients with serial stents, each stent event was evaluated separately and as part of its series. Success was defined as resolution of indicated anastomotic problem for at least 90 days. Complications were defined as development of stent-related problems.

Results

Twenty-three patients had a total of 63 stents placed (16 % prophylactic, 38 % leak, 46 % stricture). Sixty percent of patients had successful resolution of their initial anastomotic problem; 67 % required more than one stent. Strictures and leaks healed in 27 and 70 % of patients, respectively, at a median of 55.5 days. Stent-related complications occurred in 78 % of patients. Complications (per stent event) included 62 % migration, 11 % clinically significant tissue overgrowth, 8 % minor erosion (ulcers), and 8 % major erosion. Stents placed for stricture were more likely to result in complications, especially migration (76.7 vs. 48.5 %, p = 0.02). Preoperative chemoradiation was a significant risk factor for erosion (22.5 vs. 4.3 %, p = 0.05), but not for overall complications. Patients with major erosions had longer stent duration compared to those without (92 vs. 36 days, p = 0.14).

Discussion

Although stents are effective at controlling post-esophagectomy anastomotic leaks, they are not effective for treating strictures. Stents have high complication rates, but most are minor. Chemoradiation is a risk factor for stent erosion. Caution should be used when stent duration exceeds 2–3 months due to the risk of erosion.

     

Effectiveness of a Transanal Tube for the Prevention of Anastomotic Leakage after Rectal Cancer Surgery

Aim

We evaluated the effectiveness and safety of a transanal tube placed for the prevention of anastomotic leakage after rectal surgery.

Methods

Between 2007 and 2011, a total of 243 patients underwent anterior resection using the double stapling technique for rectal cancer at our institution. We excluded 67 patients with diverting stoma and divided the remaining patients into two groups: patients who did not receive a transanal tube and diverting stoma (n = 140; control group) and those who received a transanal tube (n = 36). We compared the rate of anastomotic leakage, evaluated the complications associated with the transanal tube, and analyzed the risk factors for anastomotic leakage.

Results

The following perioperative parameters were significantly different between the two groups as follows (control group vs. transanal tube group): diabetes mellitus (8 [22 %] vs. 12 [8.5 %] patients, respectively; p = 0.03), surgical duration (262 ± 54.1 min [171–457] vs. 233 ± 61.7 min [126–430], respectively; p < 0.01). The postoperative anastomosis leakage appeared significantly different between the two groups (1 [2.7 %] vs. 22 [15.7 %] patients, respectively; p = 0.04). Anastomotic leakage was significantly associated with the distance between the anastomosis line and the anal verge (odds ratio [OR] 8.58; 95 % confidence interval [CI] 1.53–48.0; p = 0.01) and non-use of a transanal tube (OR 11.1; 95 % CI 1.04–118; p = 0.04) in both univariate and multivariate analyses.

Conclusions

Placement of a transanal tube is effective in decreasing the rate of anastomotic leakage after anterior resection using the double stapling technique. However, complications associated with a transanal tube should be carefully considered.     

Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts

Background

Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Methods

This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8–15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success).

Results

Of 122 patients, 45 (36.9 %) had 10Fr stents of which 30 patients (66.7 %) had more than one stent; the remaining 77 (63.1 %) patients had 7Fr stents of which 56 (72.7 %) had more than one stent. The overall treatment success was 94.3 %. Treatment was successful in 102 patients (83.6 %) with one intervention; 13 patients (10.7 %) required re-intervention for successful drainage and 7 patients (5.7 %) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5 %, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6 %, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95 % CI 0.23–10.4) and number (OR 1.15; 95 % CI 0.25–5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression.

Conclusions

There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.     

Outcomes of second self-expandable metallic stent insertion for malignant gastric outlet obstruction

Background

Self-expandable metallic stents are used widely to relieve malignant gastric outlet obstruction (GOO). However, restenosis or migration of first stents is a frequent complication. The purpose of this retrospective cohort study was to evaluate the effectiveness of second stents as an approach to manage failure of first stents in patients with malignant GOO.

Methods

A total of 222 patients with gastric cancer received first stents due to inoperable GOO at National Cancer Center in Korea between January 2008 and June 2011. Monthly follow-up interviews were performed, and second stents (stent-in-stent or stent-after-migration) were inserted in 59 patients by June 2012. Technical and clinical successes and long-term complications were evaluated.

Results

The technical and immediate clinical success rates were 98.3 % (58/59) and 91.5 % (54/59), respectively. Patients who received a second stent due to late complications involving the first stent (migration, restenosis, and fracture) showed a higher clinical success rate (95.8 % [46/48]) than patients who received a second stent due to immediate clinical failure of the first stent (72.7 % [8/11], p = 0.04). The immediate clinical success rate of stent-after-migration (100 % [11/11]) was not different from that of stent-in-stent (89.6 % [43/48], p = 1.0). The stent dysfunction rate of stent-after-migration (27.3 % [3/11]) also was similar to that of stent-in-stent (29.2 % [14/48], p = 1.0). The median patencies of stent-in-stent and stent-after-migration were 27.4 and 58.4 weeks, respectively (p = 0.177). There were no significant prognostic factors for patency of second stents.

Conclusions

Insertion of a second stent is effective for treating the first-stent failure in gastric cancer patients with GOO, especially if the immediate outcome of the first stent was successful.     

End-to-End Cervical Esophagogastric Anastomoses Are Associated with a Higher Number of Strictures Compared with End-to-Side Anastomoses

Background

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

Methods

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

Results

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p?=?0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p?=?0.04). Moreover, a median of 11 (7–17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2–8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p?<?0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p?=?0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p?=?0.03 and p?=?0.01, respectively).

Conclusion

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.     

Outcome of functional end-to-end esophagojejunostomy in totally laparoscopic total gastrectomy

Purpose

Totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult. In fact, esophagojejunostomy is the most difficult surgical technique in TLTG. We adopted functional end-to-end anastomosis for esophagojejunostomy to simplify the procedure. The present study assesses the feasibility and surgical outcomes of TLTG with functional end-to-end esophagojejunostomy.

Methods

We assessed the intraoperative and postoperative outcomes of 65 consecutive patients who underwent TLTG with functional end-to-end esophagojejunostomy at Tonan Hospital between January 2006 and August 2011.

Results

The mean surgical duration was 271.5?±?64.7 min, and the mean blood loss was 85.2?±?143.2 g. One patient (1.5 %) was converted to open surgery, and two patients (3.1 %) required reoperation due to ileus because of an internal hernia and jejunojejunostomy leakage. No reoperation was associated with functional end-to-end esophagojejunostomy. The mean hospital stay was 21.4?±?13.5 days. Ten patients (15.4 %) developed postoperative complications, of which three (4.6 %) were anastomotic stenosis associated with functional end-to-end esophagojejunostomy. All of these were resolved by endoscopic dilation.

Conclusion

Functional end-to-end esophagojejunostomy in TLTG is safe and feasible.     

Risk Factors for Esophagojejunal Anastomotic Leakage After Elective Gastrectomy for Gastric Cancer

Objective

The aim of this study was to investigate the correlation between intraoperative anastomotic troubles and the incidence of esophagojejunal anastomotic leakage (EJAL), and to identify risk factors for EJAL after elective gastrectomy for gastric cancer.

Methods

This study reviewed the medical and surgical records of 327 patients who underwent elective gastrectomy followed by esophagojejunostomy. A multivariate analysis was performed to determine the risk factors for EJAL.

Results

An EJAL occurred in 19 patients (5.8?%). A multivariate analysis demonstrated that hemoglobin A1c ??7.0?% (p?<?0.01), chronic renal failure (p?<?0.01), proximal gastrectomy (p?<?0.05), and anastomotic trouble during construction of the esophagojejunostomy (p?<?0.01) were independent predictors for EJAL. Anastomotic trouble during construction of esophagojejunostomy occurred in 20 patients (6.1?%), and EJAL occurred in 6 of these 20 patients (30?%). Four of ten patients (40?%) in whom an incomplete anastomosis was repaired by suturing during surgery had an EJAL, while none of seven patients who underwent re-anastomosis had this complication.

Conclusions

EJAL is strongly associated with intraoperative technical errors. To reduce this complication, proper anastomotic techniques are required. Re-anastomosis should be performed when an incomplete anastomosis is discovered during surgery.     

Metallic ureteral stents in malignant ureteral obstruction: short-term results and radiological features predicting stent failure in patients with non-urological malignancies

Purpose

To provide short-term result of the metallic ureteral stent in patients with malignant ureteral obstruction and identify radiological findings predicting stent failure.

Materials and methods

The records of all patients with non-urological malignant diseases who have received metallic ureteral stents from July 2009 to March 2012 for ureteral obstruction were reviewed. Stent failure was detected by clinical symptoms and imaging studies. Survival analysis was used to estimate patency rates and factors predicting stent failure.

Results

A total of 74 patients with 130 attempts of stent insertion were included. A total of 113 (86.9 %) stents were inserted successfully and 103 (91.2 %) achieved primary patency. After excluding cases without sufficient imaging data, 94 stents were included in the survival analysis. The median functional duration of the 94 stents was 6.2 months (range 3–476 days). Obstruction in abdominal ureter (p = 0.0279) and lymphatic metastasis around ureter (p = 0.0398) were risk factors for stent failure. The median functional durations of the stents for abdominal and pelvic obstructions were 4.5 months (range 3–263 days) and 6.5 months (range 4–476 days), respectively. The median durations of the stents with and without lymphatic metastasis were 5.3 months (range 4–398 days) and 7.8 months (range 31–476 days), respectively.

Conclusion

Metallic ureteral stents are effective and safe in relieving ureteral obstructions resulting from non-urological malignancies, and abdominal ureteral obstruction and lymphatic metastasis around ureter were associated with shorter functional duration.     

Management of distal malignant biliary obstruction with the ComVi stent, a new covered metallic stent

Background

The covered metallic stent is effective for managing malignant distal biliary obstructions. The most popular covered metallic stent is the covered Wallstent (CWS). This study estimated the efficacy and safety of a new expanded polytetrafluoroethylene (e-PTFE)-covered nitinol metallic stent, the ComVi stent. This covered metallic stent consists of an e-PTFE membrane sandwiched between two uncovered metallic stents with weak axial (straightening) force. Wire is exposed on both the inner and outer surfaces.

Methods

Between May 2005 and April 2007, ComVi stents were placed consecutively in 47 patients with unresectable malignant distal biliary obstruction. The cases involved 35 pancreatic cancers, 8 metastatic nodes, 2 gallbladder cancers, and 2 bile duct cancers. The patients were compared with 47 patients who received CWS placement between August 2001 and May 2005 matched for age, sex, and causative disease from 133 cases.

Results

No significant differences in stent patency or patient survival were found. Stent occlusion was observed in 13 patients (27.7%) in the ComVi group and 10 patients (21.3%) in the CWS group. The cause of occlusion in both groups was tumor overgrowth (4.25% vs 4.2%), sludge (8.5% vs 6.3%), impaction of food scraps (14.9% vs 2.1%), and bile duct kinking (0% vs 8.4%). Other complications were migration (2.1% vs 17.0%; p = 0.0304) and cholecystitis (2.1% vs 6.3%), and there were significant differences in the incidence of complications except for occlusion (4.2% vs 24.6%; p = 0.0142).

Conclusion

The ComVi stent has a patency similar to that of the CWS and a lower incidence of migration. However, early occlusion by food impaction was increased and should be resolved.     

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

Background

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

Methods

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

Results

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54 %. The overall success in terms of preventing mortality was 96 %.

Conclusion

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.     

Feasibility and Impact on Surgical Outcomes of Modified Double-Stapling Technique for Patients Undergoing Laparoscopic Anterior Resection

Background

Anastomotic leakage is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate the modified double-stapling technique (MDST), as an alternative for conventional double-stapling technique (DST), and whether it could reduce the anastomotic leakage rate in laparoscopic anterior resection (Lapa-AR).

Study Design

Between March 2009 and October 2010, a total of 189 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectosigmoid colon were divided into the MDST group (n?=?95) and the DST group (n?=?94) according to the anastomotic technique. Data were analyzed retrospectively. Morbidity and anastomotic leakage rate were compared between the two groups.

Results

Patient demographics, preoperative comorbidity, tumor size, stage, and operative details were comparable between the two groups. There was no difference in operation time between the two groups. The overall complication rate was significantly lower in the MDST group than in the DST group (3.2 vs. 10.6 %, p?=?0.042), including anastomotic leakage rate (0 vs.4.6 %, p?=?0.029). The anastomotic technique was the only factor associated with anastomotic leakage in univariate analysis.

Conclusions

Our comparative study demonstrates MDST to have better short-term outcome in reducing anastomotic leakage compared with DST. This technique could be an alternative approach to maximize the patients' benefit in laparoscopic anterior resection.     

Colon anastomotic leakage: improving the mouse model

Purpose

Colon anastomotic leakage remains a serious and common surgical complication. Animal models are valuable to determine the pathophysiological mechanisms and to evaluate possible methods of prevention. The aim of this study was to develop an optimal model of clinical colon anastomotic leakage in a technically insufficient anastomosis in the mouse.

Methods

A total of 110 mice were used in three pilot studies (1–3) and two experiments (A, B). Due to the high complication rates, the analgesic regimen and surgical techniques were changed throughout the pilot studies/experiments. In the final successful experiment (B), eight and four absorbable sutures were used in the control and intervention anastomoses, respectively, and buprenorphine in chocolate spread was used for pain treatment.

Results

In the final model (experiment B), significantly more animals in the intervention group had clinical anastomotic leakage compared with controls (40 vs. 0 %, p = 0.003). The weight loss was greater and the wellness score was also lower in these animals (p < 0.001). The breaking strength of the anastomoses was not significantly different between the control group [0.55 N ± 0.09] and intervention group [0.49 N ± 0.15] (p = 0.091).

Conclusions

This mouse model closely mimics clinical colon anastomotic leakage in humans. The model is of high clinical relevance, since anastomotic leakage has a similar cause, incidence and manifestations in humans.     

Oncologic safety of stent as bridge to surgery compared to emergency radical surgery for left-sided colorectal cancer obstruction

Background

There are still concerns about the oncologic safety of stent insertion for colorectal cancer obstruction. This study investigated whether the use of stents as a bridge to surgery negatively affect the long-term outcome compared to curative surgery for left-sided colorectal cancer obstruction.

Methods

Between January 2004 and December 2009, patients with left-sided colorectal cancer obstruction without distant metastasis were retrospectively reviewed. Forty-three patients underwent radical resection after preoperative stent insertion (stent group), whereas 48 underwent emergency surgery with curative intent (surgery group). The short- and long-term outcomes between the two groups were compared.

Results

The stent and surgery groups had similar demographics. There were no significant differences in primary anastomosis, laparoscopic-assisted surgery, operation time, time until first defecation and oral intake after surgery, postoperative hospital stay, and reoperation. The stent group had an average hospital stay 7 days longer than the surgery group. During the median follow-up period of 48.1 months, the 5-year disease-free survival rates were not significantly different between the stent and surgery groups (47.2 vs. 48.9 %, respectively; p = 0.499). Overall, the 5-year survival rate was also similar in the two groups (70.4 vs. 76.4 %, respectively; p = 0.941).

Conclusions

For left-sided colorectal cancer obstruction, stent insertion followed by surgery showed short-term advantages and similar oncologic outcomes compared to surgery without preoperative intervention. Stent insertion as a bridge to surgery is a safe and feasible treatment option for patients with colorectal cancer obstruction.     

Selective Mediastinal Lymphadenectomy Without Intraoperative Frozen Section Examinations for Clinical Stage I Non-Small-Cell Lung Cancer: Retrospective Study of 403 Cases

Objective

The extent of mediastinal lymphadenectomy for clinical stage I non-small-cell lung cancer (NSCLC) remains controversial. This study explored the value of selective mediastinal lymphadenectomy from the clinical viewpoint.

Methods

From 2005 to 2008, a total of 403 patients diagnosed clinically as having stage I NSCLC underwent lobectomy and mediastinal lymph node dissection. Among them, 309 underwent complete mediastinal lymphadenectomy, and the other 94 underwent selective mediastinal lymphadenectomy. We compared the perioperative parameters and overall survival statistics for the two groups retrospectively.

Results

The two groups had no significant differences in sex, pathology, tumor location, or preoperative staging. The selective mediastinal lymphadenectomy group had an older average age, with a much higher rate of patients >70 years of age (p = 0.016). Also, the patients were apt to undergo thoracoscopic lobectomy (p = 0.044). This group had shorter operating times and less intraoperative bleeding. No significant differences in total drainage volume, length of hospital stay, or complication rates were found between the two groups. The mean follow-up periods were 35.8 ± 13.7 vs. 34.6 ± 17.2 months. Local and distant recurrence rates were 25.6 % vs. 30.9 %, respectively (p = 0.560). The 3-year and 5-year overall survival rates were 83.0 % and 74.6 % vs. 75.1 % and 68.5 %, respectively (p = 0.216).

Conclusions

For patients with clinical stage I NSCLC, selective mediastinal lymphadenectomy can reduce the trauma caused by the procedure, especially for elderly patients and those with co-morbidities. Survival was acceptable and was no worse than that after complete mediastinal lymphadenectomy. Our results need to be confirmed by prospective randomized controlled studies.     

Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer

Background

Few clinical studies to date have compared different types of self-expandable metallic stents (SEMS) and their outcomes in patients with pure duodenal obstruction caused by pancreaticobiliary cancer. The aim of this study was to compare the clinical effectiveness and side effects of uncovered and covered SEMS for the palliation of duodenal obstruction caused by pancreaticobiliary cancer.

Methods

We retrospectively analyzed all patients with pancreaticobiliary cancer who underwent upper endoscopy with SEMS placement for malignant duodenal obstruction at the National Cancer Center of Korea between April 2003 and December 2010. The technical and clinical success rates of the procedure, complications, and durations of stent patency and overall survival were evaluated.

Results

We identified 70 patients with a mean age of 51.2 years (range = 39–81 years); of these, 46 (65.7 %) had pancreatic cancer, 9 (12.9 %) had bile duct cancer, 11 (15.7 %) had gallbladder cancer, and 4 (5.7 %) had cancer of the ampulla of Vater. Twenty-four patients (34.3 %) received covered SEMSs and 46 (65.7 %) received uncovered SEMSs. Technical and clinical success rates were similar for the covered and uncovered stent groups. The complication rate was higher in the covered than in the uncovered group (62.5 vs. 34.8 %, P = 0.025), due primarily to a significantly higher stent migration rate (20.8 vs. 0 %, P = 0.004). Perforation as a late complication occurred in four patients, two in each group (8.3 vs. 4.3 %, P = 0.425). Stent patency tended to be shorter for covered than for uncovered duodenal stents (13.7 ± 8.6 weeks vs. not reached, P = 0.069).

Conclusions

The use of uncovered stents may be a preferred option for duodenal obstruction secondary to pancreaticobiliary malignancies, since they were effective in preventing stent migration and tended to have longer patency than covered stents. Careful attention should be paid to signs and symptoms of perforation during follow-up.     

Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction

Background

Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy.

Methods

Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency.

Results

Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65 %), pancreatic cancer in nine patients (15 %), ovarian cancer in three patients (5 %) and other causes in nine patients (15 %). The clinical success rates were similar between the two groups (92.6 vs 86.7 %; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9 %) and 18 patients with extracolonic malignancy (30 %) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3 %; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy.

Conclusions

Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.     

Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience

Background

Fully covered self-expanding metal stents (FCSEMS), unlike partially covered SEMS (PCSEMS), have been used to treat benign as well as malignant conditions. We aimed to evaluate the outcome of PCSEMS and FCSEMS in patients with both benign and malignant esophageal diseases.

Methods

Data were reviewed of all patients who underwent SEMS placement for malignant or benign conditions between January 1995 and January 2012. Patients with cancer were followed for at least 3 months, until death or surgery. Patients with benign conditions had stents removed between 4 and 12 weeks. Patient demographics, location and type of lesion, stent placement and removal, clinical success, and adverse events were analyzed.

Results

A total of 252 patients (mean ± standard deviation age 68.5 ± 14 years; 171 male) received 321 SEMS (209 PCSEMS, 112 FCSEMS) for malignant (78 %) and benign (22 %) conditions. Stent placement and removal was successful in 97.6 and 95.6 % procedures. Successful relief of malignant dysphagia was noted in 140 of 167 patients (83.8 %) and control of benign fistulas, leaks, and perforations was noted in 21 of 25 patients (84 %), but only 8 of 15 patients (53 %) with recalcitrant benign strictures had effective treatment. Fifty-six patients (22.2 %) experienced at least one stent-related adverse events. Migration was frequent, occurring in 61 of 321 stent placements (19 %), and more frequently with FCSEMS than PCSEMS (37.5 vs. 9.1 %, p < 0.001). FCSEMS, benign conditions, and distal location were the variables independently associated with migration (p < 0.001, p = 0.022, and p = 0.008). Patients with PCSEMS were more likely to have tissue in- or overgrowth than FCSEMS (53.4 vs. 29.1 %, p = 0.004).

Conclusions

Both PCSEMS and FCSEMS can be used in benign and malignant conditions; they are both effective for relieving malignant dysphagia and for closing leaks and perforations, but they seem less effective for relieving benign recalcitrant strictures. Stent migration is more common with FCSEMS, which may limit its use for the palliation of malignant dysphagia.     

Predictive score for anastomotic leakage after elective colorectal cancer surgery: a decision making tool for choice of protective measures

Background

Anastomotic leakage is the most severe complication after colorectal surgery and a major cause of postoperative morbidity and mortality. We aimed to identify a predictive score for postoperative leakage after colorectal cancer surgery and to evaluate its usefulness in assessing various protective measures.

Methods

A total of 159 patients were divided into test (79 patients) and validation (40 patients) groups in order to identify the risk factors and construct the predictive score. The remaining 40 patients (intervention group) were prospectively evaluated with the application of protective measures guided by risk stratification according to the predictive score.

Results

A total of 23 of 159 (14.5 %) patients had anastomotic leakage, with 7 of 23 (30.4 %) of them needing reoperation. 11 of 159 (6.9 %) patients died, with 10 (6.3 %) deaths directly associated with anastomotic leakage. The rate of leakage in the test and validation groups (nonintervention group) was 22 of 119 (18.5 %), while the rate of leakage in the intervention group was 3 of 40 (7.5 %). The odds ratio for anastomotic leakage in the intervention group was 0.23 compared to the nonintervention group, with a relative risk reduction of 73 % for unfavorable event. The number needed to treat was 8 patients. There were also 10 of 119 (8.4 %) deaths in the nonintervention group compared to 1 of 40 (2.5 %) in the intervention group (Fisher’s test; p = 0.18).

Conclusions

Our simple predictive score may be a valuable decision making tool that can help surgeons reliably identify patients at high risk for postoperative anastomotic leakage and apply guided intraoperative protective measures.     

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

Background

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

Methods

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

Results

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p?=?ns) and 100 and 96.6% (p?>?0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p?=?0.274) and 13.7 and 16.7% (p?=?0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p?=?0.761) and 25.9, 15, and 0% (p?=?0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

Conclusions

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.